PROJECT SUMMARY/ABSTRACT Patients who are hospitalized with acute respiratory failure frequently receive intensive care and mechanical ventilation, often toward the goals of life extension and return to independence. Those with chronic life-limiting illness are at particularly high risk of developing acute respiratory failure. However, many chronically ill patients may desire a palliative approach to care that prioritizes symptom relief over life extension. In these patients, the use of intensive care and mechanical ventilation for respiratory failure is likely to be misaligned with their individual goals. Such care is referred to as goal-discordant care. To improve concordance between patients? goals and their medical care, paradigms in advance care planning have sought to translate patients? goals into pre-specified healthcare decisions for future illnesses; one such approach is the Physician Orders for Life- Sustaining Treatment (POLST) form, a portable physician order that specifies treatment limitations for emergency care. However, POLST limitations are frequently reversed during acute illness, and some of these reversals are likely to be incongruous with the patient?s goals. Understanding the ways in which discordance arises between patients? goals, their documented preferences, and the care they receive will inform efforts to measure and improve the delivery of goal-concordant care. As a means to understand how goal-discordance may be defined, measured, and modified, this proposed mixed methods study examines the occurrence of POLST-discordant mechanical ventilation and intensive care with two specific aims: (Aim 1) Using quantitative methods, identify risk factors for receiving POLST-discordant care near the end of life in decedents with chronic life-limiting illness hospitalized with acute respiratory failure; and, (Aim 2) using qualitative methods, identify etiologies of POLST-discordant care in these decedents through thematic analysis of (a) semi-structured interviews with family members and healthcare providers exploring decision-making and communication, and (b) electronic health record documentation of the treatment decision-making process. These aims will increase understanding of the epidemiology, risk factors, and etiologies of goal-discordant care. The proposed study will draw from a novel, data-rich cohort of over 25,000 patients with chronic life-limiting illness who died in Washington State and received care through the University of Washington healthcare system. The findings of the proposed study will offer critical insights that will be used to identify patients at high risk for goal-discordant care, and develop interventions that improve the delivery of patient-centered, goal-concordant care to patients hospitalized with acute respiratory failure.